VA Advance Directive Worksheet - Mental Health Preferences - US Department of Veterans Affairs

Mental Health Care Preferences

If you have a serious mental health condition, you should let your doctors and loved ones know your wishes for mental health care. This is just as important as letting them know your wishes for other types of medical care. Think about your experiences with your mental health condition. If you recognize signs that your mental health is getting worse, you may want your providers and loved ones to know those signs, too. Have certain treatments or drugs helped you while others haven’t? Have you been hospitalized before? If so, was it helpful? You may have had either good or bad experiences with other approaches your providers have tried, too.

You can use this worksheet to:  Record your mental health care choices.  Ensure that your spokesperson, loved ones, and health care providers clearly understand your wishes.

Be sure to discuss your choices with your spokesperson, loved ones, and health care providers. You may attach a copy of this worksheet to your VA Advance Directive if you choose to complete one. Be sure to initial each page. If you do this, VA will treat the worksheet as part of your directive. Please review this worksheet with your spokesperson, loved ones, and health care providers before you attach it to your advance directive. Talk to your legal advisor if you want a state-authorized mental health advance directive. Your advisor can help you incorporate your preferences onto that document.

This worksheet has four parts:  Mental Health Symptoms  Medication and Treatment Preferences for Mental Health  Entering a Mental Health Facility  Other Information and Preferences

Mental Health Symptoms

The signs that my mental health condition may be getting worse include:

1 Initial here:______Date last updated:______

Medication and Treatment Preferences for Mental Health

I prefer to receive the following medications, therapies, and other treatments (if indicated) because they helped me when my symptoms were worse:

If reasonable alternatives exist, I would like to avoid the following treatments. Identify the reasons for your preferences, such as bad side effects, concern about long-term side effects, or that the medication didn’t work when your symptoms were worse:

I understand that medications may cause side effects. However, if there are reasonable alternatives, I especially would like to avoid the following bad side effects. Check up to four:

 Unusual movements of my mouth or other areas

 Numbness (loss of sensation)

 Motor restlessness (not being able to sit still or stand without moving around)

 Seizures (In a seizure, your body twitches or shakes for a brief period of time. You can’t control your body and you usually become unconscious.)

 Stiffness in my muscles or body, so that I can’t move my arms, legs, or body smoothly or normally

 Tremors (An example of a tremor is when your hands shake or vibrate very fast and you can’t control it.)

 Nausea or vomitting (feeling sick to your stomach or throwing up)

2 Initial here:______Date last updated:______

 Gaining weight

 Losing weight

 Diabetes (Diabetes is a condition that causes problems maintaining your normal level of blood sugar, It’s sometimes called the “sugar disease.”)

 Problems with my sexual functioning

 Addiction or dependence to the medication(s)

 Other:

Entering a Mental Health Facility

If I need serious and short-term (acute) emergency mental health care because I can’t take care of myself, I prefer that my doctors consider an alternative to hospitalization. Examples of these alternatives are acute follow-up, mental health case management, and prompt follow-up with an outpatient mental health provider.

 Yes (Name or describe the alternative(s)):

 No

If I need to be hospitalized for mental health problems, I prefer to be in the following programs/facilities. Identify the reasons for your preferences:

Program/Facility: Reason:

3 Initial here:______Date last updated:______Program/Facility: Reason:

Program/Facility: Reason:

Other information and Preferences

The staff of the hospital or crisis unit should know that the following things might help me get my mental health symptoms under control:

The staff should know that the following things might help me relax and be less agitated, and also might lessen the need to restrain me and keep me by myself (in seclusion):

I have these additional preferences for my mental health treatments:

Initial here:______Date last updated:______